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Sunday, July 8, 2012

Acute renal failure (ARF) or Acute Kidney Injury (AKI) is a rapid loss (breakdown or decrease) of renal function due to damage to the kidneys, resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products that are normally excreted by the kidney.

Acute Renal Failure (ARF) is classified as :

Pre Renal; occurs as a result of renal hypoperfusion which usually responds well to rehydration, or result from condition that diminish blood flow to the kidney.

Intra Renal; result from damage to the kidneys, usually from acute tubular necrosis. In critically ill patients other insults such as infection, hypoxia, drugs etc, may convert a simple problem of poor perfusion into one of acute tubular necrosis where there is structural damage to the renal parenchyma. The patient may not die from renal failure although this may be present at the time of death. There is a high mortality in patients who develop ARF in the context of other severe illness.

Post Renal (obstructive); result from bilateral obstruction of urine flow. The most common cause of obstructive uropathy in men is prostate.

Acute renal failure has four phases : onset, oliguric-anuric, diuretic and convalescent. The convalescent period can last up to 12 months.

Nursing care plan (NCP) or nursing intervention for the patients who diagnosed as acute renal failure during admitted on the hospital should be complete, comprehensive monitor and quick action in order to improve of patient's condition.

A. Assessment Findings on Acute Renal Failure

During assessment, the nurses may find some sign and symptom of acute renal failure. There are many complain from patient related to his/her condition such as ; Anorexia, Nausea, Vomiting, Costovertebral plain, Headache, diarrhea or constipation, Irritability, Restlessness, Lethargy, Drowsiness, Stupor, Coma, Pallor, Ecchymosis, Stomatitis, Thick tenaciouse sputum, Urine output less than 400 ml/day for 1 to 2 weeks and then followed by diuresis (3 to 5 L/day) for 2 to 3 weeks, Weight gain.

The client will understand the means by which His/Her family members will implement health teaching after discharge.

G. Nursing Intervention for Acute Renal Failure

To the nursing intervention, the nurses should be have good knowledge to decide which phase of his/her patient related to the acute renal failure. Base on that information, bellow are some nursing intervention they can do to the patient with acute renal failure :

* Oliguric-anuric phase ; In this phase, the client's urine output falls bellow 400 ml/day. With resultant electrolyte imbalance, metabolic acidosis, and retention of nitrogenouse wastes from non functioning nephrons. This pahse may last up to 14 days. The Nurses should be follow these steps :

Maintain the client on complete bed rest, organize care to provide long rest periods. Activity increase the rate of metabolism, which increase production of nitrogenouse waste product.

Implement intervention to prevent infection and the complications of immobility. Because She/He is on bed rest, the client becomes susceptible to the hazards of immobility. Infection is a serious risk and the leading cause of death in client with acute renal failure.

Observe the client for metabolic acidosis to identify complication of renal failure.Observe the fluid and electrolyte balance hourly.

Insert an indwelling urinary catheter and measure output and specific gravity hourly. These action allow the nurse to monitor the kidneys, which have the major role in regulating fluid and electolyte balance. High potassium levels can occur.

Monitor the client's diet to provide high carbohydrates, adequate fats, and low protein. If client receives high calories from fat and carbohydrate metabolism, the body doesn't break down protein for energy. Protein is thus available for growth and repair.

* Early diuretic phase ; During early diuretic phase, which last about 10 days, the client excretes a large volume (over 3,0000 ml/day) of very dilute urine. The glomeruli are beginning to function effectively, but tubules aren't, and the client still experiences electrolyte imbalance, retention of nitrogenous waste product and metabolism acidosis. The nurse should be do intervention such as ;

Assess fluid and electrolyte balance to identify continued fluid and electrolyte imbalance when the renal tubules aren't functioning.

Assess the emotional status of the client and family members to provide support because the prognosis is still uncertain.

Continue interventions used during the oliguric phase.

* Late Diuretic phase ; In the late diuretic phase, the client is still excreting more fluid than normal. Urine specific gravity is increasing because the tubules are beginning to function effectively. Fluid, electrolyte and acid-base balances are returning to normal. In this condition, The nurse should do the following steps ;

Continuing implementations of the early diuretic phase. Allow the client to engage in nonstrenuous activity for brief periods and increase the activity level gradually. Don't let him/her become fatigued which may increase the rate of metabolism and overwork the kidneys.

Teach the client to prevent infection and to avoid the factors that caused renal failure to help prevent a recurrence.